United States District Court, N.D. Alabama, Middle Division
MEMORANDUM OPINION AND ORDER OF REMAND
Claimant,
Antonio Shropshire, commenced this action on February 21,
2017, pursuant to 42 U.S.C. § 405(g), seeking judicial
review of a final adverse decision of the Commissioner,
affirming the decision of the Administrative Law Judge
(“ALJ”), and thereby denying his claim for a
period of disability, disability insurance, and supplemental
security income benefits.
The
court's role in reviewing claims brought under the Social
Security Act is a narrow one. The scope of review is limited
to determining whether there is substantial evidence in the
record as a whole to support the findings of the
Commissioner, and whether correct legal standards were
applied. See Lamb v. Bowen, 847 F.2d 698, 701 (11th
Cir. 1988); Tieniber v. Heckler, 720 F.2d 1251, 1253
(11th Cir. 1983).
Claimant
contends that the Commissioner's decision is neither
supported by substantial evidence nor in accordance with
applicable legal standards. Specifically, claimant asserts
that the ALJ: (1) failed to order an additional psychological
evaluation; (2) failed to state adequate reasons for finding
claimant's subjective complaints to be less than fully
credible; (3) failed to find that claimant met Listings 12.04
and 12.06; (4) entered a residual functional capacity finding
that was not supported by substantial evidence; (5) failed to
give proper weight to the opinion of Dr. Jack Bentley, the
consultative psychologist; and, (6) failed to assess the
intensity and persistence of claimant's symptoms pursuant
to Social Security Ruling 16-3p. He also argues that the
Appeals Council failed to properly review new evidence
submitted after the date of the ALJ's decision.
The
court finds merit in claimant's first and fifth
arguments, both of which concern the consultative
psychological examination of Jack Bentley, Ph.D., who
examined claimant at the request of the
Commissioner on April 12, 2014, and issued a
report on April 18, 2014. Claimant reported experiencing
psychiatric problems after joining the Air Force in 2001. He
worked as a medic in a military hospital, where he
“encountered numerous individuals with multiple
traumatic injuries suffered in the wars in Iraq and
Afghanistan.”[1] After that, claimant began experiencing
“flashbacks, nightmares, panic attacks, periodic crying
spells, paranoia, rages and a marked loss of
self-esteem.”[2] Claimant was treated with medication
prescribed by a VA psychiatrist, but the medication did not
make a significant difference, and the severity of his
flashbacks and nightmares was gradually escalating. After
being honorably discharged from the Air Force in 2010,
claimant attempted to return to college, but he “could
not tolerate being in a classroom with other students,
” and he was failing all of his classes.[3] He also attempted
to work in an emergency room, but he could not tolerate the
atmosphere “and seeing individuals with traumatic
injuries.”[4]
During
the clinical examination, claimant exhibited no obvious
limitation of memory or communication skills. His mood was
moderately dysphoric, and his affect was restricted. There
was evidence of anxiety, restlessness, and some
hypervigilence. Claimant insisted that the door to the
examination room remain open, and he was suspicious that
someone might be trying to enter the room during the
examination. There was evidence of obsessional thinking, but
no history of auditory or visual hallucinations.
Additionally, Dr. Bentley observed:
[Claimant] is alert and oriented. The patient did recall two
of three objects after a five-minute delay. Mr. Shropshire
did recite six digits forward and four backwards. The
claimant indicated that there [are] 48 weeks in a year, the
sun rises in the East[, ] and Shakespeare [is the] author of
Hamlet. He stated that Brazil is in South America. The
patient accurately interpreted one of two proverbs and
provided the analogy in three of three abstractions. The
patient was able to perform serial 7's and 3's from
100. The client stated the names of national, state and local
leaders. He correctly counted backwards from 20 to 1.
Tr. 309 (alterations supplied).
Claimant
reported that his sleep often was disturbed by his
obsessional thinking and anxiety, but those problems improved
after he began taking Benadryl at night. Claimant attends
church periodically with his family, but he otherwise rarely
leaves home due to his mistrust of strangers. He has no
hobbies, but he is able to carry out his daily living
activities without assistance.
Dr.
Bentley assessed claimant as experiencing post-traumatic
stress disorder (“PTSD”) with marked paranoid
features and multiple health problems. Dr. Bentley stated
that claimant had developed PTSD as a result of his work as
an Air Force medic. His symptoms - including flashbacks,
nightmares, and panic attacks - had escalated, and he
experienced “marked paranoia” at the time of the
exam. In summary, Dr. Bentley stated:
The claimant is judged to be able to manage any funds that he
may be awarded. The prognosis for his current level of
functioning is considered favorable. There was no evidence of
symptom exaggeration. He has reasonable insight into the
etiology of his symptoms. The severity of his PTSD would
substantially limit him from sustaining complex or repetitive
tasks. His paranoia would further limit his ability to
communicate effectively with coworkers and supervisors. These
same symptoms would also limit his ability to work at a
normal pace. Mr. Shropshire would appear only capable of
sustaining simple work-related decisions in a non-stressful
environment that requires little communication with fellow
employees.
Tr. 310.
The ALJ
stated that he afforded only little weight to Dr.
Bentley's assessment, because
Dr. Bentley is not an acceptable medical source and
cannot make a medical diagnosis that can be considered a
medically determinable impairment . . . . Furthermore,
his assessment is largely based on the claimant's
self-reported symptoms and is not supported by the limited
treatment evidence of record, which shows that the ...